Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Thursday, January 15, 2009

Alternative Medicine's Last Gasp

I just got back from dinner, turned on my laptop, checked my e-mail and was treated to this simplistic, idealistic take on alternative medicine as the cure-all for our health care crisis (and for coronary heart disease in particular) by none other than our now infamous promoters of preventing all that ails us: Deepak Chopra, Dean Ornish, Rustum Roy and Andrew Weil. I don't know how I missed this.

In a near breathless twist of of statistics, dripping with such cynicism it would make one's head spin, we hear:

The choices are especially clear in cardiology. In 2006, for example, according to data provided by the American Heart Association, 1.3 million coronary angioplasty procedures were performed at an average cost of $48,399 each, or more than $60 billion; and 448,000 coronary bypass operations were performed at a cost of $99,743 each, or more than $44 billion. In other words, Americans spent more than $100 billion in 2006 for these two procedures alone.

Despite these costs, a randomized controlled trial published in April 2007 in The New England Journal of Medicine found that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (i.e., 95% of those who receive them). Coronary bypass surgery prolongs life in less than 3% of patients who receive it. So, Medicare and other insurers and individuals pay billions for surgical procedures like angioplasty and bypass surgery that are usually dangerous, invasive, expensive and largely ineffective.

While there are clearly patients who have received unnecessary angioplasty (and likely bypass) procedures, the authors conveniently fail to mention the benefits these procedures provide for patients suffering from angina pectoris and exertional dyspnea from ischemic coronary disease. Angioplasties and bypass are often not performed to "prevent heart attacks" or "prolong life" but rather to relieve symptoms.

The authors also discuss the INTERHEART trial, a case-control trial which evaluated risk factors in 15,152 incident cases of acute MI and 14,820 controls matched by age (± 5 years) and sex but with no history of heart disease from self-reported survey data, chart reviews, and a single physical exam and blood collection before discharge. Unfortunately, only 12,461 of the MI cases and 9459 controls were analyzed (that's right, over one third of controls were lost to follow-up).

Now, (who knew?) the heart attack patients were more likely to have larger abdominal girth, smoke, have a higher apoB/apoA1 ratio, have diabetes, and be stressed. Okay, I'll agree they found a statistical correlation.

But then they make some audacious claims: like if everyone just ate vegetables, stopped smoking, fixed their lipids, rid themselves of their diabetes and lost weight, 90% of heart disease could be prevented!!!!!

What the...?

Heelllllooooo! Anybody home? What does a case control study say anything about cause and effect?

Simply put: absolutely nothing.

The INTERHEART trial's design to determine outcome effect of the correlations was limited in every type of major research bias going: selection bias (including referral bias and non-respondent bias), measurement bias (self-reported questionnaires, memory bias), and intervention bias (contamination bias, timing bias, compliance bias, and very likely proficiency bias from multiple countries performing the evaluation). The audacity to suggest that changing lifesyles would affect the outcome of coronary disease to such an extent (90%) based on this single trial is clearly overreaching and outright dishonest.

A case in point: when the all-knowing Ornish's own diet was compared head-to-head on a prospective, randomized basis to the several others, it was not superior for weight loss or cholesterol lowering. So if their diet had limitations, what does this say about it's effects on preventing heart disease?

But the voodoo doesn't stop there:

Integrative medicine approaches such as plant-based diets, yoga, meditation and psychosocial support may stop or even reverse the progression of coronary heart disease, diabetes, hypertension, prostate cancer, obesity, hypercholesterolemia and other chronic conditions.

Prostate cancer? Are they serious?

But alas, they are. So serious in fact that they never seem to find it in their hearts to discuss all the interactions that can occur between their herbal concoctions and supplements and conventional medications. (You mean there can be problems with herbs? Say it ain't so!)

But then, there might be an ulterior motive to promoting this approach, like this or this.

But the real reason for this opinion piece was placed in the Wall Street Journal?

These approaches emphasize both personal responsibility and the opportunity to make affordable, quality health care available to those who most need it. Mr. Obama should make them an integral part of his health plan as soon as possible.

These guys know the government is looking to cut costs, and (fortunately and correctly) their workshop will be first to suffer the fall of the axe.

This seems to be a somewhat philosophical dispute between the disciplines of traditional medicine and so called alternative medicine. One relies heavily upon science and double blind plcebo controlled studies, while the other relies more on practitioner experience. On some level, both can be subject to abuse and overrepresentation of stated benefits. In point of fact, many therapies are introduced before they are clearly proven to have benefit in traditional medicine and later found to be unhelpful, or worse yet, harmful. Are you old enough to have had your tonsils yanked out years ago as millions of children did, or to have radiation therapy for acne before we found out this was not such a great idea? Sometimes modern medicine is just as guilty as are the scam artists who sell all varities of snake oil to alleviate your woes and ailments.Lets face it; for many of the medical conditions for which traditional medicine does not work, at least some will get relief from these presumably sham treatments since there is a well recognised 30% placebo effect from any treatment. Why is it accepted to treat patients with terminal conditions and little hope of survival with very expensive medical treatments but not to give them less tested methods of alternative treatment. Both, in most instances, serve the purpose of offering some ray of hope to the patient and little more. I often wonder which is really better for a terminal cancer; an operative procedure followed by toxic chemotherapy that results in the last months of life being a living hell, or some sham treatment that does not worsen the patients condition. On top of this, one creates a huge expense with little benefit (guess which one!).One could be critical of these scam artists who reap profit from desperate patients in search of a cure, but I think traditional medicine has its share of scam artists as well, wrapped in the cloak of science, when often the science is not very convincing to begin with. For instance, ther is currently no clear proof that diagnosing and excising a mans prostate offers any benefit in expanded life span, yet we subject patients to this routinely. Is this an alternative form of therapy or are we praciticing goo evience based medicine?

"One relies heavily upon science and double blind plcebo controlled studies, while the other relies more on practitioner experience. On some level, both can be subject to abuse and overrepresentation of stated benefits."

While both can be subject to abuse and overrepresentation of stated benefits, we could also argue that to let someone die might be the most cost-effective treatment strategy for our health care system. In fact, the improved longevity of patients is now coming back to haunt us as our population gets older. Does this mean we should not attempt to prolong life or relieve suffering because it is not cost effective? What we don't see are the societal benefits to this longevity since this will never be captured on spread sheets. To the individual patient, however, it’s often priceless.

I do not think we should confuse Complementary and Alternative Medicine (CAM) techniques with good, traditional medical care that includes referral (where appropriate) to palliative (and hospice) therapy. But many of the CAM methods employed by these individuals also have side effects but we never hear about those, do we? What effect will taking herbal remedies and delaying chemo have on certain leulemias? We can only guess.

I have no problem with people spending their own money on CAM if they are so inclined, but I have a BIG problem with paying $121 million a year for NCCAM and another $121 million for a division of the National Cancer Institute called the "Office of Complementary and Alternative Medicine." Together, taxpayers are funding nearly a quarter of a billion dollars for these offices of woo medicine with little in return.

Finally, when these authors attempt to suggest a treatment effect from their therapies based on case control population studies, and claim it can "prevent" disease and save taxpayer money, we should all expose these unsubstantiated claims.

All your points are well taken. But I personally have found some benefit to the NIH fune studies. I can now tell my patients who ask about these treatments that a study was performed and showed no benefit from whatever herb and root they are inquiring about. Before all I could do was shrug my shoulders and say nobody knows if what these guys purport is true.

My other point was simply to show that there is a gray zone in traditional medicine of treatments that are of questionable benefit as well, but we don't spend the time to make this clear to patients. Where is the proven benefit of surgery for prostate cancer? Is Plavix really that superior for post stent patients to justify a price tag of a hundred times more than aspirin? Are we examining the potential negative effects of repeated CT scans in patients from cummulative radiation exposure, or have we conveniently overlooked this potential side effect? Why do we blythly ignore the wide differentials in practice patterns and cost across this country which seem to correlate so well with the number of doctors, despite no measurable change in health measures? Should we really be employing Da Vinci robotic systems in evry hospital until their beneifts are clearly proven?

While the fraud may not be as blatant as with instances of CAM where we have no basis in fact or experience, my point was that modern medicine does its share of hawking its wares as well.

I think that has more to do with the failure of science education in the schools, than the current medical climate. Perhaps we need some climate change.

One relies heavily upon science and double blind plcebo controlled studies, while the other relies more on practitioner experience.

Science is the best, most objective method of discriminating among potentially helpful treatments. While practitioner experience may suggest hypotheses for investigation, or treatments to be studied, only science will be able to show which deserve further investigation.

Are you old enough to have had your tonsils yanked out years ago as millions of children did, or to have radiation therapy for acne before we found out this was not such a great idea?

That is one of the great things about science. Science changes as we learn more. Science is a Bayesian process. We study, we learn, we adapt, we study some more. We continually repeat this process.

Science makes mistakes, but science is self correcting.

You cannot say the same about the alternative medicine community, since there is little research. The science seems to be a misuse of the word. I got as far as the changing lifestyle could prevent at least 90% of all heart disease part of the article and i realized that these are still just snake oil salesmen. They will kill people with their kindness. And even Shakespeare would not approve of that, although he might write a great tragedy about it.

Why do we blythly ignore the wide differentials in practice patterns and cost across this country

There are plenty of people, who are not blithely ignoring treatments that lack evidence to support them. Traditional medical treatments are thoroughly investigated, criticized, and discarded when found wanting. If only alternative medicine could say the same.

Traditional medicine is actually a misnomer, since part of that tradition is a commitment to science. Science is the antithesis of tradition.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.